Disability Benefits Questionnaires (Group 4)

ICR 201903-2900-012

OMB: 2900-0781

Federal Form Document

Forms and Documents
Document
Name
Status
Form
Modified
Supporting Statement A
2019-09-30
Supplementary Document
2019-08-06
Supplementary Document
2019-05-07
IC Document Collections
IC ID
Document
Title
Status
196008 Modified
ICR Details
2900-0781 201903-2900-012
Historical Active 201511-2900-002
VA VBA-COMP-NK
Disability Benefits Questionnaires (Group 4)
Extension without change of a currently approved collection   No
Regular
Approved without change 12/23/2019
Retrieve Notice of Action (NOA) 10/01/2019
VBA shall review the forms in this collection to determine if they are voluntary or required to obtain and retain a benefit and ensure that in the next revision or extension request that this information is correct in the Privacy statement and consistent across the forms in this collection. VBA shall also ensure that such information is in plain language.
  Inventory as of this Action Requested Previously Approved
12/31/2022 36 Months From Approved 12/31/2019
160,000 0 160,000
53,750 0 53,750
0 0 0

Group 4 (DBQs) are used to assist veteran's who require a disability examination in support of a claim for VA benefits. These forms are used to record the findings of the examining physician.

US Code: 38 USC 501(a) Name of Law: Rules and Regulations
  
None

Not associated with rulemaking

  84 FR 9203 05/06/2019
84 FR 16024 07/29/2019
No

1
IC Title Form No. Form Name
Disability Benefits Questionnaires (Group 4) VA Form 21-0960I-4, VA Form 21-0960D-1, VA Form 21-0960E-2, VA Form 21-0960E-3, VA Form 21-0960H-1, VA Form 21-0960I-3, VA Form 21-0960I-5, VA Form 21-0960L-1, VA Form 21-0960Q-1, VA Form 21-0960J-4, VA Form 21-0960N-3, VA Form 21-0960N-4, VA Form 21-0960C-3, VA Form 21-0960C-6, VA Form 21-0960C-7, VA Form 21-0960C-11, VA Form 21-0960I-2 Cranial Nerves Diseases Disability Benefits Questionnaire ,   Narcolepsy Disability Benefits Questionnaire ,   Fibromyalgia Disability Benefits Questionnaire ,   Seizure Disorders (Epilepsy) Disability Benefits Questionnaire ,   Hernias (Including Abdominal, Inguinal and Femoral Hernias) Disability Benefits Questionnaire ,   HIV-Related Illnesses Disability Benefits Questionnaire ,   Infectious Diseases (Other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis) Disability Benefits Questionnaire ,   Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases Disability Benefits Questionnaire ,   Nutritional Deficiencies Disability Benefits Questionnaire ,   Oral and Dental Conditions Including Mouth, Lips and Tongue (Other than Temporomandibular Joint Conditions) Disability Benefits Questionnaire ,   Endocrine Diseases (Other than Thyroid, Parathyroid or Diabetes Mellitus) Disability Benefits Questionnaire ,   Thyroid and Parathyroid Conditions ,   Urinary Tract (Including Bladder and Urethra Conditions) (Excluding Male Reproductive System Disability Benefits Questionnaire ,   Respiratory Conditions (Other than Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire ,   Loss of Sense of Smell and/or Taste Disability Benefits Questionnaire ,   Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx Disability Benefits Questionnaire ,   Chronic Fatigue Syndrome Disability Benefits Questionnaire

  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 160,000 160,000 0 0 0 0
Annual Time Burden (Hours) 53,750 53,750 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$14,348,071
No
    Yes
    Yes
No
No
No
Uncollected
Danny Green 202 421-1354 danny.green2@va.gov

  No

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
10/01/2019


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